Multi-dimensional healthcare

Revolutionary new treatments for cancer or genetic diseases grab the headlines. But with the cost of treating chronic and preventable illnesses increasing sharply across both advanced and emerging countries, the healthcare industry needs a new approach, one that  takes into account the multiple influences on human health -- including social policies and the activities of commercial enterprises. 

It bears repeating that clean water, better sanitation, high quality education and stable employment all decrease global morbidity and improve life expectancy more than any cutting-edge health technology. Lack of access to safe water alone accounts for 1.2 million premature deaths globally.¹ 

These social dimensions aren’t only critical to developing countries, which lack critical infrastructure. 

Even within the richest countries, groups of people who live just a few kilometres apart can have significantly different life expectancies, despite theoretically having access to the same basic social, health and education services. 

For instance, in Glasgow, Scotland, there is a 17.6 year life expectancy gap between two neighbourhoods at either extreme, broadly reflecting the gap between the city’s poorest and richest deciles.²

There is no quick fix for these problems. What’s needed is a holistic approach to healthcare that acknowledges the multiple determinants of health. Within this, prevention takes pole position.

Health as a social phenomenon

At least since the end of the 19th century, policymakers have been aware of the complex interplay between social factors and health. This was most famously brought to public attention by the German physician Rudolf  Virchow, whose report into an outbreak of typhus in Silesia in 1848 identified poor living conditions as the root cause. 

More broadly, research has shown that “a higher ratio of social service spending versus healthcare spending results in improved population health,” according to the Massachusetts Medical Society in a 2017 report. For its part, the World Health Organization gives three overarching recommendations for improving health outcomes: improve daily living conditions; tackle the inequitable distribution of power, money and resources; and measure and understand the problem and assess the impact of action.³ 

All of which underscores how difficult it is to improve health and wellbeing on global scale. For instance, fixing unhealthy environments frequently involves the interplay of finance, urban planning, agriculture, industry and transport. 

Tackling poor diet and nutrition, meanwhile, involves education, finance, agriculture and industry. But given that 20 per cent of people – the sickest and most underprivileged – generate 80 per cent of healthcare costs the rewards of well-structured social programmes are significant. 

Fairly apportioning costs

A multi-dimensional approach to healthcare also requires an understanding of how commercial activities impact our health. These can be positive and negative.

For example, businesses that produce and sell harmful products such as tobacco, alcohol, ultra-processed food and fossil fuels are together estimated to cause at least a third of preventable deaths per year globally. In doing so, they are leaving governments and consumers to shoulder cost of this damage – such as paying for healthcare or cleaning up oil spills or commercial waste.⁴ These so-called externalities mean many of these products are sold at artificially cheap prices relative to their true costs – of inputs as well as the social and economic costs borne by others – leading to greater consumption and higher profits for these industries. 

“This means that the more harm and damage commercial actors cause, the more they increase their profits, wealth and power. At the same time, the individuals, communities and governments who have to meet these costs have less resources and power, making it harder to hold commercial actors to account,” said a recent Lancet report of these commercial determinants of health.

It is a fair assumption that companies of all stripes will increasingly be forced to account for these externalities - not only to their customers, but also to their shareholders and regulators. 

New approaches to prevention

Yet it is also true that the private sector has made an invaluable contribution to our wellbeing. Commercial nous and investment means consumers now have access to an ever-expanding range of goods and services necessary for a healthy life, such as nutritious food, quality healthcare, medicine and housing.

In some cases, without private sector involvement, many serious diseases would remain untreated. 

Take obesity. Excess body mass is associated with diabetes, heart disease and higher rates of cancer. It is a serious global problem. Governments and health authorities have tried various measures. Education and urban planning to encourage physical activity. They’ve tried to incentivise agriculture and industry to produce and promote healthier food. But these measures have done little to slow the overall trend towards overweight. 

Which is why health authorities are latching onto the new generation of weight-loss drugs. These have been shown to be effective at helping people lose weight and keep it off by controlling their appetites, much more so than dieting and other traditional approaches. The question for policymakers now is the degree to which they’re willing to pay for medication that needs to be taken for as long as the weight loss is to be sustained – once patients stop taking the drugs, their appetites and weight returns. Another important consideration for those paying for the drugs is how much cardiovascular benefits the drugs could bring, analysis should be available later this year.  Then there’s the matter of unpleasant side-effects. But the effectiveness of the drugs is enough to have attracted the attention of the UK’s National Health Service.

One difficulty with a multi-dimensional approach to preventative healthcare is finding the workers to help. For many hospitals, the bottleneck is no longer in high tech machines, but the people to run them. Hospital administrators are struggling to find enough medical and nursing staff to meet demand. Home care provision is even tighter – which threatens to put an even bigger burden on hospitals, because an inability to monitor the vulnerable at home will often precipitate medical emergencies. One way around this is remote monitoring through teleconferencing systems. So a nurse who might have only been able to see two or three patients at their homes in a morning, can now monitor a dozen. Elderly patients are often on rosters of medications – ensuring they take the right ones in the correct order can be a challenge. Remote monitoring/teledoc and e-nurse via video can all help. 

The evidence is that prevention is powerful. Globally, it is more effective than medical intervention at prolonging life and the quality of life. But it also involves considerable complexity. Different parts of society need to work together in a coordinated way to produce the best results. And sometimes they need to be helped by technology.

This article was based on the Pictet Health Thematic Advisory Board discussions.